LOD compared to medical interventions for symptom relief in women with polycystic ovary syndrome

Patient or population: Women with symptoms of PCOS
Setting: Clinic or hospital
Intervention: Laparoscopic ovarian drilling (LOD)
Comparison: medical interventions

Menstrual regularity at 6 months

LOD vs metformin
N of participants: 236 (2 RCTs)

LOD vs metformin + clomiphene
N of participants: 332 (2 RCTs)

LOD vs gonadotropins
N of participants: 35 (1 RCT)

LOD vs letrozole
N of participants: 260 (1 RCT)

LOD vs metformin + letrozole
N of participants: 146 (1 RCT)

⊕⊝⊝⊝
VERY LOW ^{1, 2, 3}

71.0%
(60.5 to 79.7)

0.4% more
(10 fewer to 9.2 more)

⊕⊕⊝⊝
LOW ^{1, 3}

70.6%
(28.4 to 93.6)

59.5% more
(17.3 more to 82.5 more)

⊕⊕⊝⊝
LOW ^{1, 3}

70.4%
(58.5 to 80.2)

1.6% more
(10.3 fewer to 11.4 more)

⊕⊕⊝⊝
LOW ^{1, 3}

50.8%
(34.7 to 66.3)

1.3% fewer
(17.3 fewer to 14.2 more)

⊕⊕⊝⊝
LOW ^{1, 3}

Improvement in androgenic symptoms at 6 months (hirsutism/acne) ‐ LOD vs metformin
N of participants: 126
(1 RCT)

79.4%
(61.8 to 90.1)

0.0% fewer
(17.6 fewer to 10.7 more)

⊕⊕⊝⊝
LOW ^{1, 3}

Improvement in androgenic symptoms at 6 months (hirsutism/acne) ‐ LOD vs gonadotrophins
N of participants: 50 (1 RCT)

⊕⊝⊝⊝VERY LOW ^{1, 4}

Acne: 4/29 without LOD, 1/21 with LOD

Hirsutism: 3/29 without LOD, 1/21 with LOD

Harms: GI Upset at 6 months ‐ LOD vs metformin + clomiphene
N of participants: 332 (2 RCTs)

Harms: OHSS rates at 6 months ‐ LOD vs gonadotrophins
N of participants: 33 (1 RCT)

0.6%
(0.1 to 4.0)

9.9% fewer
(10.3 fewer to 6.4 fewer)

⊕⊕⊕⊝
MODERATE ¹

2.6%
(0.0 to 34.9)

22.4% fewer
(25 fewer to 9.9 more)

⊕⊕⊝⊝
LOW ^{1, 3}

*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio; OHSS: ovarian hyperstimulation syndrome

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

LOD compared to other surgical interventions for symptom relief in women with polycystic ovary syndrome

Patient or population: Women with symptoms of PCOS
Setting: Clinic or hospital
Intervention: LOD
Comparison: other surgical interventions

Menstrual regularity ‐ LOD vs unilateral LOD
N of participants: 104
(2 RCTs)

78.8%
(60.5 to 90.1)

7.7% more
(10.7 fewer to 19 more)

⊕⊕⊕⊝
MODERATE ¹

1 study follow‐up at 3 months. 1 study follow‐up at 12 months

Menstrual regularity at 6 months ‐ LOD vs ultrasound‐guided transvaginal ovarian drilling
N of participants: 147
(1 RCT)

59.7%
(43.6 to 74.1)

5.1% more
(11.1 fewer to 19.4 more)

⊕⊕⊝⊝
LOW ^{1 2}

Menstrual regularity at 12 months
Laser LOD vs harmonic scalpel
N of participants: 34
(1 RCT)

94.1%
(56.0 to 99.5)

5.9% more
(32.2 fewer to 11.3 more)

⊕⊕⊝⊝
LOW ^{1, 3}

Note control group is NdYAG Laser

Improvement in androgenic symptoms at 6 months (Acne) ‐ LOD vs USS guided
N of participants:31
(1 RCT)

42.7%
(15.1 to 75.7)

4.3% fewer
(32 fewer to 28.6 more)

⊕⊕⊝⊝
LOW ^{1, 2}

Improvement in androgenic symptoms at 6 months (Hirsutism) ‐ LOD vs USS‐guided
N of participants: 39
(1 RCT)

42.1% (16.7 to 72.3)

2.1% more (23.3 fewer to 32.3 more)

⊕⊕⊝⊝
LOW ^{1, 2}

Harms: Adhesions at 6 months ‐ LOD vs THL
N of participants: 246
(1 RCT)

12.7%
(6.8 to 20.8)

46.6% fewer
(52.5 fewer to 38.5 fewer)

⊕⊝⊝⊝
VERY LOW ^{1, 4}

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio; THL: transvaginal hydrolaparoscopy

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

LOD 4 ‐ 5 punctures compared to 2 or fewer punctures for symptom relief in women with polycystic ovary syndrome

Patient or population: Women with symptoms of PCOS
Setting: Clinic or hospital
Intervention: LOD 4 ‐ 5 punctures
Comparison: 2 or fewer punctures

Menstrual regularity at 6 months ‐ LOD 4 ‐ 5 coagulation points compared to 2 or fewer
N of participants: 73
(2 RCTs)

72.1%
(40.3 to 90.8)

58.2% more
(26.4 more to 76.9 more)

⊕⊕⊝⊝
LOW ^{1, 2}

Menstrual regularity at 6 months ‐ LOD (4 ‐ 5 laser coagulation points) vs 1 laser coagulation point per ovary
N of participants: 40
(1 RCT)

50.0%
(10.0 to 90.0)

45.0% more
(5 more to 85 more)

⊕⊕⊝⊝
LOW ^{1, 2}

Menstrual regularity at 6 months ‐ LOD 4 punctures vs 2 punctures per ovary
N of participants: 33
(1 RCT)

82.4%
(46.4 to 96.2)

57.4% more
(21.4 more to 71.2 more)

⊕⊕⊝⊝
LOW ^{1, 2}

Improvement in androgenic symptoms

Harms

LOD 4 ‐ 5 versus fewer punctures

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

LOD compared to LOD variable energy for symptom relief in women with polycystic ovary syndrome

Patient or population: Women with symptoms of PCOS
Setting: Clinic or hospital
Intervention: LOD
Comparison: LOD variable energy

Menstrual regularity at 6 months ‐ LOD vs adjusted thermal dose
N of participants: 115
(1 RCT)

75.4%
(53.8 to 89.3)

12.6% fewer
(34.1 fewer to 1.3 more)

⊕⊝⊝⊝
VERY LOW ^{1, 2}

Menstrual regularity at 3 months ‐ LOD unipolar vs LOD bipolar
N of participants: 20
(1 RCT)

90.0%
(31.0 to 99.4)

0.0% fewer
(59 fewer to 9.4 more)

⊕⊝⊝⊝
VERY LOW ^{1, 2}

Groups had different metabolic characteristics at baseline

Improvement in androgenic symptoms

Harms: Adhesions at 6 months
№ of participants: 64
(1 study)

27.7%
(11.3 to 53.5)

0.8% fewer
(17.2 fewer to 25 more)

⊕⊝⊝⊝

VERY LOW^{1, 2}

Women that remained enrolled for second‐look laparoscopy

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect